Objective : We performed breast fine needle aspiration cytology (FNA) at the bedside using the rapid turnaround Giemsa staining method (Diff-Quik). Herein, we report the quality control of our breast FNA and the usefulness of the bedside cytology in reducing the inadequate specimen rate.

Study Design : We reviewed 3034 breast FNAs performed during the 5-year period from January 2006 to December 2010 at Mie University Hospital Breast Center. All the breast FNAs were performed by breast surgeons under ultrasound guidance. Cytology smears were stained by the Diff-Quik method at the bedside, and information on the collected amount of cells and the tentative diagnosis was immediately fed back to the operator. The final diagnoses were made in smears stained with Papanicolaou stain.

Results : The average inadequate specimen rate during the study period was 7.8%, fluctuating among the years from 3.9% to 16.4%, and was affected by the skill level of the operator.

Conclusions : Bedside cytology with rapid turnaround Giemsa staining is useful for reducing the inadequate specimen rate, because of the real-time feedback provided to the operator on the quantity of cells collected and the tentative diagnosis.

Objective : To be consistent in the definition of atypical squamous cells undetermined significance (ASC-US), we temporally assessed the transition of status in patients diagnosed as having ASC-US after introduction of the Bethesda system (TBS).

Study Design : We compared the frequency, age distribution, Human papillomavirus (HPV) status and histological results of patients with ASC-US between two 3-year periods : the first of 2008 to 2010 and the second from 2011 to 2013.

Results : In first 3-year period, 309 (0.13%) cases of ASC-US were diagnosed from 236121 participants in uterine cervical cancer screening. In second 3-year period, 341 (0.15%) cases of ASC-US were diagnosed from 221143 participants. The proportion of ASC-US with abnormal cytology decreased to 16.8% in the second period from 18.6% in the first. In the first period, 85 patients (30.7%) with≥cervical intraepithelial neoplasm 2 (CIN2) were detected from 309 patients with ASC-US. In the second period, 45 patients (19.7%) with≥CIN2 were detected from 341 patients with ASC-US. There was a significant decrease in high grade lesions in the second period from the first period (p=0.006).

Conclusion : In the temporal spread over two periods to examine the concept of ASC-US, decrease in the frequency of abnormal cytology in ASC-US and in the detection rate of≥CIN2 were seen in the second period. It may demonstrate an adequate status in the diagnosis of ASC-US.

Background : Gangliocytic paraganglioma (GP), a rare tumor occurring almost exclusively adjacent to the ampulla of “papilla of Vater”, is composed of three components, although the amounts of each of these components are highly variable. Since these tumors are usually recognized as submucosal tumors, they are seldom diagnosed by endoscopic biopsy. Although EUS-FNA is a promising sampling method for the diagnosis, the cytological features have not yet been fully elucidated.

Case : A man in his sixties visited us complaining of tarry stools. Gastrointestinal endoscopy revealed a duodenal pedunculated tumor adjacent to the ampulla of “papilla of Vater”. However, repeated endoscopic biopsies failed to show the tumor components clearly. EUS-FNA cytology revealed tumor cells composed of three types of cells, including epithelioid cells with fine granular chromatin reminiscent of neuroendocrine cells, ganglion-like large cells with prominent nucleoli, and spindle-shaped cells. These findings suggested the possibility of GP. Pancreatico-duodenectomy was performed. Histologically, the tumor located within the submucosal region was composed of the three aforementioned types of cells : epithelioid cells, ganglion-like cells, and spindle-shaped cells.

Conclusion : We encountered a case of GP and reviewed the cytological findings. This tumor is characterized by its characteristic localization, macroscopic findings and cytological findings. If the three cellular components can be properly identified by EUS-FNA, GP can be diagnosed cytologically.

Background : The disease formerly known as primary neuroendocrine tumor of the breast is currently classified according to the recent World Health Organization (WHO) classification system as “carcinoma with neuroendocrine features” (CNF). Herein, we report the cytological findings of 4 cases of CNF.

Cases : All the patients were women, three of whom were in the eighth decade of life and one in the fifth. The initial symptoms were palpable tumor and brown-colored nipple discharge. Cytological specimens were obtained by fine needle aspiration cytology (FNAC). The cytological findings in case 1 were similar to those of small cell carcinoma derived from the lung and other organs. On the basis of the findings, the diagnosis of CNF, neuroendocrine carcinoma poorly differentiated/small cell carcinoma (NEC) was successfully made. On the other hand, cases 2-4 showed diverse cytological findings and we failed to diagnosis CNF prior to histological examination. Immnohistochemically, more than 50% of the tumor cells were positive for neuroendocrine markars in all cases, which led to a conclusive diagnosis of CNF in all the cases.

Conclusion : We encountered 4 cases of CNF of the breast in which the cytological findings were available prior to histological examination. In cases with cytological findings resembling those of NEC, the histological diagnosis can be predicted. However, when the cytology shows varied findings, as in cases 2-4, prediction of the histology might be difficult.

Background : Clear cell sarcoma is a rare soft tissue tumor, recently renamed as neuroectodermal tumor of melanocytic origin.

Case : A 76-year-old man presented with a soft tissue tumor in the right lateral chest wall. MRI revealed findings suggestive of an irregular-shaped hemorrhagic malignant tumor, and surgical resection was carried out after biopsy. Imprint smear of the extirpated tumor revealed polygonal and spindle-shaped cells cytoplasm with oval nuclei and rough granular chromatin with prominent nucleoli, and intranuclear cytoplasmic inclusions. Intracytoplasmic melanin was not seen. Histologically the tumor was composed of compact nests of polygonal cells with occasional cells having clear cytoplasm, and the tumor cells were immunohistochemically positive for vimentin, S-100 protein and Melan-A ; transcripts of the EWSR1-ATF1 fusion gene were also identified.

Conclusion : The soft tissue tumor without melanin, was difficult to diagnose as a clear cell sarcoma, as both the site of the tumor and age of the patient were atypical. When similar cytological findings to those in this case are observed, clear cell sarcoma should be considered in the differential diagnosis.

Background : Herein, we report a case of TX lung cancer that was successfully diagnosed by liquid based cytology (LBC) from metastatic mandibular and thyroid lesions.

Case : A woman in her 80 s presented to us with the chief complaint of swelling and pain of her right cheek. CT and MRI examinations revealed tumor masses in the right mandible and atlas. FDG accumulation was observed in the masses of the right mandible and atlas, with nodular accumulation also observed in the left lobe of the thyroid gland. A plain x-ray of the chest and chest CT were normal. No abnormal accumulation in the chest was observed on FDG-PET. The LBC sample obtained from the right mandible demonstrated cohesive tumor cells with a hobnail-like structure. Immunostaining showed positive results for TTF-1 and Napsin A. Similar tumor cells were identified in the FNA LBC sample from the left lobe of the thyroid gland. In addition, EGFR L858R gene mutations were detected from FNA LBC sample. Immunostaining of the biopsy specimen obtained from the right mandibular tumor revealed positive staining of the tumor cells for TTF-1 and Napsin A. Thus, the patient was finally diagnosed as having TX lung adenocarcinoma.

Conclusion : The results in this patient encourage us to actively use LBC methods for analyzing even patients with carcinoma of unknown primary.

Background : Allergic bronchopulmonary aspergillosis (ABPA) is caused by type-Ⅰ and type-Ⅲ hypersensitivity reactions to bronchial-colonizing Aspergillus. Usually, the diagnosis of ABPA is established based on clinical, serologic, and radiologic criteria. Cytology of bronchial fluid specimens, such as bronchoalveolar lavage fluid (BALF), is not commonly performed in ABPA patients. We report a case of ABPA with the characteristic cytologic features of BALF.

Case : A 79-year-old female patient came to our hospital because of an asthma attack. She was diagnosed as having ABPA on the basis of the Rosenberg-Patterson criteria. Cytology of BALF showed mucus with aggregates of eosinophils, Charcot-Leyden crystals, and scattered septate hyphae that branched dichotomously. BALF culture grew Aspergillus sp.

Conclusion : ABPA should be included in the differential diagnosis if mucus with aggregates of eosinophils and septate hyphae showing dichotomous branching are found on cytologic examination of bronchial fluid specimens.

Background : Collagenous spherulosis (CS) consists of intraluminal clusters of small cells and hyalinized spherules, simulating cribriform growth. We describe the cytological aspects and stainability of the components in the spherules.

Case : A female in her fifties was detected as having a mass in the breast by ultrasonography. Fine-needle aspiration cytology revealed interstitial mucinous spherules (MS) and hyalinized spherules. The MS ranged in diameter from 44 to 110 μm. Among of them, intermediate-sized MS surrounded by cuboid cells with round nuclei showed pale purple staining. Small-sized MS showed light green staining. A few had a star-shaped structure inside. Hyalinized spherules measured approximately 40 μm in diameter, and were stained green. Immunocytochemically, the hyalinized spherules showed positive staining for type Ⅳ collagen and laminin, and positive PAS reaction. The cells with naked oval nuclei rimming the hyalinized spherules were positive staining for p63. Within the cell clusters, the cells in the vicinity of the hyalinized spherules showed positive staining for p63, while the cells that were located away were negative for p63.

Conclusion : CS is composed of spherical basement membrane material produced by myoepithelial cells. The presence of CS, so-called hyalinized spherules, suggests the presence of mature myoepithelial cells. Therefore, CS is can become a predictive factor of breast benign lesions.

Background : Pleural fluid involvement by salivary gland tumors is extremely rare. We report the second documented case, to the best of our knowledge, of salivary duct carcinoma (SDC) with pleural effusion, successfully diagnosed by immunocytochemical staining.

Case : A 57-year-old male with a past history of SDC of the right submandibular gland 4 years earlier, presented to us with the findings of a massive right pleural effusion. Papanicolaou staining of the pleural fluid revealed many neoplastic cells in clusters. These cells had relatively rich granular or vacuolated cytoplasm and eccentric large round to oval nuclei containing fine granular chromatin and conspicuous nucleoli. Intracytoplasmic lumina were observed. Immunocytochemical analysis demonstrated positive reactivity for the androgen receptor, therefore, a cytodiagnosis of SDC was made, taking into consideration the past history of the patient. Histopathological analysis of the pleural nodule revealed the diagnosis of metastatic SDC.

Conclusion : Cytodiagnosis of adenocarcinoma is not difficult in cases of SDC with pleural involvement. However, a definitive diagnosis of SDC may be difficult, and a combination of the past history and immunocytochemical staining for AR is useful.

We report a case of clear cell tumor of the lung (CCTL) in a male in his 40’s. Imprint cytology revealed epithelioid cell clusters with clear or granular cytoplasm and small round or short spindle-shaped nuclei.

Scattered intranuclear inclusion bodies were noted. Immunocytochemically, the tumor cells were positive for HMB-45. Although CCTL is a rare entity, a knowledge of the characteristic cytologic and immunocytochemical findings including positivity for HMB-45 is helpful for making a correct diagnosis of CCTL.